4 Lapins J, Emtestam L, Marcusson JA. Angiokeratomas in Fabry's disease and Fordyce's disease: successful treatment with copper vapour laser. Acta Derm Venereol (Stockh) 1993; 73: 133-5. 5 Möhrenschlager M, Braun-Falco M, Ring J, Abeck D. Fabry disease: recognition and management of cutaneous manifestations. Am J Clin Dermatol 2003; 4: 189-96.The application of topical tacrolimus in vesicular pemphigoid SIR, Bullous pemphigoid (BP) occurs mainly in elderly patients, and is associated with high morbidity and sometimes mortality. 1 Advanced patient age and high doses of systemic corticosteroids are major risk factors for mortality. 2 Vesicular pemphigoid (VP) is an uncommon variant of BP.We describe a patient with VP for whom topical steroids did not achieve good symptomatic control, but the use of topical tacrolimus has spared the need for long-term systemic treatment.A 69-year-old retired businessman had generalized pruritus for 6 months. His past health was good. He was a nonsmoker and social drinker. He had been taking hypnotic agents occasionally as prescribed by a psychiatrist. His medication history was otherwise unremarkable. Examination revealed a lean elderly man with no pallor and no jaundice. Generalized excoriation marks were evident. A tense and firm-topped vesicle 4 mm in diameter was seen on the left side of his chest. Dermatoscopic examination revealed clear fluid in the vesicle, with inflammatory vascular changes evident at the periphery of the lesion. Nikolsky's sign was negative. The patient stated that similar vesicles had erupted before, and pointed out various healing or healed lesions with postinflammatory hyperpigmentation on the chest wall, axillae, abdomen, forearms, thighs and legs. The lesions were not arranged in groups. Palmoplantar surfaces and mucous membranes were uninvolved.Full blood count, fasting glucose, liver, renal and thyroid function tests were normal. Antinuclear antibodies and rheumatoid factor were negative. Biopsy of the active lesion revealed a subepidermal vesicle. Exocytosis of inflammatory cells with a predominance of eosinophils was seen. Mild epidermal spongiosis and focal parakeratosis were noted. Direct immunofluorescence for IgG and C3 revealed positive staining along the basement membrane. Staining for IgA and IgM was negative. Staining for fibrin was faintly positive along the basement membrane and base of the vesicle.The clinical, histopathological and immunofluorescence findings were all consistent with VP. More fresh intact vesicles were noted at subsequent visits. We prescribed oral prednisolone 20 mg daily (0AE4 mg kg )1 daily) with oral cimetidine 400 mg daily. The systemic corticosteroid was tapered to a dose of 5 mg on alternate days (0AE05 mg kg )1 daily). Topical clobetasol propionate 0AE05% ointment was then commenced. However, new lesions continued to erupt. We then commenced topical tacrolimus ointment twice daily, first at 0AE03% and then at 0AE1%. After 2 weeks, the oral prednisolone was stopped altogether. No further new lesions were seen. Th...